Report a Claim

To report a new claim on-line, please complete the form below. Note that some information is mandatory in order to complete the claim reporting process. Click on the "Submit Claim" button when complete.

All fields marked with asterisk (*) are required.

Person Reporting the Claim

First Name*

Last Name*

Email

Best Contact Number*

Work Phone Number

Cell Phone Number

Address (street, city, state, zip)

Year

Make

Model

Driver Name

Is the Vehicle Driveable?

Yes No

Name, address, and phone number of repair shop or towing company (if applicable)

Policy Holder

Click if same as person reporting claim

First Name

Last Name

Policy Number*

Home Phone Number

Work Phone Number

Cell Phone Number

Address (street, city, state, zip)

Year

Make

Model

Driver Name

Is the Vehicle Driveable?

Yes No

Name, address, and phone number of repair shop or towing company (if applicable)

Other Vehicle Involved in Accident

Year

Make

Model

Driver Name

Is the Vehicle Driveable?

Yes No

Name, address, and phone number of repair shop or towing company (if applicable)

Accident Information

Date of Accident*

Time of Accident*

Street or Intersection*

City and State*

Describe what happened. Be sure to list the names of any witnesses or injured passengers. Also describe any injuries which may have occurred*.

Additional Information*

Yes No Did the police respond?
Police Agency		Police Report #
Yes No Did an ambulance respond?
Yes No Were there any injuries?
Yes No Were any citations issued?
Yes No Were any vehicles towed?
Yes No Was weather a factor?
Rain Hail Snow Ice Other
Yes No Do you need a Spanish speaking representative?